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GENERAL MEDICINE CONFERENCE

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Title: GENERAL MEDICINE CONFERENCE


1
GENERAL MEDICINE CONFERENCE
  • HYPERTHYROIDISM
  • Selim Krim, MD
  • Assistant Professor
  • Texas Tech University Health Sciences Center

2
SIGNS AND SYMPTOMS
  • Skin Increased Sweating and heat intolerance,
    onycholysis, hyperpigmentation, pruritus and
    thinning of the hair.
  • Eyes Stare and lid lag, exophtalmos if graves
    disease
  • Cardiac Palpitations, exertional dyspnea,
    anginal-like chest pain, tachycardia, atrial
    fibrillation, CHF
  • GI Weight loss, diarrhea
  • Neuro-psych Anxiety, restlessness, irritability,
    emotional lability, psychosis, agitation, and
    depression
  • Metabolic/Endocrine Hyperglycemia, low serum
    total and high-density lipoprotein (HDL)
    cholesterol

3
GRAVES DISEASE
  • Signs and symptoms of hyperthyroidism
  • Exopthalmos, proptosis, lid lag, orbital edema
  • Diffuse goiter
  • TSH receptor antibodies
  • Increased RAI uptake

4
MUST KNOW
  • T4 and T3 are produced in thyroid gland but T3 is
    the active component.
  • T3 can also come form T4.
  • T4-to-T3 conversion is stopped by starvation,
    liver disease and certain drugs
    (propylthiouracil, propranolol, prednisone)
  • T4 and T3 are circulating as bound proteins-TBG
    (thyroid binding globulin)
  • If TBG goes up-T4 and T3 would go up. If TBG goes
    down-T4 and T3 would go down.

5
GENERAL RULE
  • Hyperthyroidism with a high radioiodine uptake
    indicates de novo synthesis of hormone.
  • Hyperthyroidism with a low radioiodine uptake
    indicates either inflammation and destruction of
    thyroid tissue with release of preformed hormone
    into the circulation, or an extrathyroidal source
    of thyroid hormone.

6
FACTITIOUS VS. SUBACUTE THYROIDITIS
FACTITIOUS HYPERTHYROIDISM SUBACUTE THYROIDITIS
THYROID GLAND Painless gland Painful gland
SERUM THYROGLOBULIN Low/Normal High
SEDIMENTATION RATE Normal High
7
DIFFERENTIATING THE THREE TYPES OF THYROIDITIS
Subacute thyroiditis/Viral thyroiditis/de Quervains thyroiditis Silent or painless thyroiditis (Chronic lymphocytic) Hashimotos thyroiditis (Painless goiter)
Viral Idiopathic mainly in women, typically 3-12 months after pregnancy (Postpartum thyroiditis) Autoimmune. Multinodular goiter is the outstanding feature.
High ESR with fever Normal ESR High or normal ESR
High T4 and T3 early on-later low T4 and T3. Low RAIU Anti-thyroglobulin antibodies are usually elevated. TPO antibodies usually normal. High T4 and T3 with low TSH initially, then Low RAIU, low T4 and T3. Anti-thyroglobulin antibodies may or may not be elevated. TPO elevated in 75 of cases. Initially eu, hyper- or hypo, eventually hypothyroid. Low RAIU. Anti-thyroglobulin antibodies are present in 85 of cases. TPO in 95 of cases.
Aspirin/Steroids Beta-blockers if needed Levothyroxine if needed
8
INDICATIONS FOR SURGERY
  • Patients with very large goiters
  • Goiters causing upper airway obstruction or
    severe dysphagia
  • In a patient who also has a nonfunctional thyroid
    nodule, which can be a thyroid cancer, surgery
    can both cure the hyperthyroidism and remove the
    nodule.
  • Moderate to severe Graves' ophthalmopathy,
  • Pregnant women who are allergic to antithyroid
    drugs and/or are tolerating hyperthyroidism
    poorly

9
Case 1
  • A 27-year-old woman is evaluated for
    palpitations and heat intolerance that develop 3
    months after a successful pregnancy. She is
    breastfeeding. The patient's older sister has
    Graves' disease, but the patient herself has no
    history of thyroid disease. On physical
    examination, the blood pressure is 128/70 mm Hg,
    and the pulse rate is 104/min. Eye examination
    reveals stare and lid lag, but no proptosis. The
    thyroid gland is moderately enlarged and
    nontender. She has moist palms and brisk deep
    tendon reflexes. Serum free T4 is 2.7 ng/dL (34.2
    pmol/L), free T3 46.22 ng/dL (7.1 pmol/L), and
    thyroid-stimulating hormone (TSH) is
    undetectable. Which one of the following is the
    most appropriate next step in this patient's
    management?
  • A- Serum anti-thyroid peroxidase
    antibodies
  • B- Serum thyroglobulin level
  • C- Serum TSH immunoglobulins
  • D- An empiric trial of antithyroid drugs
  • E- Radioiodine (I-131) uptake and thyroid
    scan

10
Case 2
  • A 27-year-old male athlete is evaluated for
    frontal headache, palpitations, and heat
    intolerance and an elevated serum
    thyroid-stimulating hormone (TSH) level. On
    physical examination, the blood pressure is
    147/78 mm Hg, a pulse rate of 88/min, and a
    mildly enlarged thyroid gland. He has a fine
    tremor, moist palms, and deep tendon reflexes are
    brisk. On laboratory testing, serum free T4 is
    2.9 ng/dL (38.0 pmol/L) and TSH is 6.8 µU/mL (6.8
    mU/L). Antithyroid peroxidase and
    antithyroglobulin antibodies are negative. Which
    of the following is the most appropriate next
    test in the evaluation of this patient?
  • A- MRI of the pituitary
  • B- Thyroid function testing of family
    members
  • C- Radioactive iodine uptake and thyroid
    scan
  • D- Serum thyroglobulin level
  • E- Thyroid stimulating immunoglobulins

11
Case 3
  • 65-year-old man with refractory atrial
    fibrillation begins therapy with amiodarone.
    Baseline thyroid hormone levels are normal. One
    month later, the patient is asymptomatic but has
    the following laboratory findings total T4, 13.4
    µg/dL (172.46 nmol/L) free T4, 2.7 ng/dL (34.2
    pmol/L) free T3, 11.72 ng/dL (1.8 nmol/L) TSH,
    3.9 µU/mL (3.9 mU/L). Which of the following is
    the most likely explanation for these findings?
  • A- Amiodarone-induced thyroiditis
  • B- Iodine-induced hyperthyroidism
  • C- Expected changes in euthyroid patients
    taking amiodarone
  • D- Spurious laboratory results caused by
    amiodarone
  • E- Euthyroid sick syndrome

12
Case 4
  • A 24-year-old woman is evaluated for
    palpitations and sweating that began 4 weeks
    after she delivered her first child 8 weeks ago.
    She has had occasional loose stools. Otherwise,
    she has felt generally well. She nursed her baby
    for 6 weeks but decided to stop 2 weeks ago. Her
    family history is unremarkable. She is taking
    multivitamins but no other supplements. On
    physical examination, the blood pressure is
    110/60 mm Hg, pulse rate 92/min, and BMI 23.7.
    The thyroid gland is normal size, slightly firm
    in consistency, and nontender. Thyroid-stimulating
    hormonelt0.01µU/mL, free T43.4ng/dL, total
    T3315ng/dL, radioiodine uptakelt1. Thyroid scan
    not visualized. Which of the following is the
    most appropriate therapy for this patient?
  • A- Radioactive iodine (I-131)
  • B- Ăź-Blocker
  • C- Prednisone
  • D- Propylthiouracil
  • E- Aspirin

13
Case 5
  • A 59-year-old woman is evaluated for a
    2-week history of diffuse arthralgias, malaise,
    anorexia, and left-sided neck pain and swelling.
    The pain radiates upwards towards the left ear.
    She has no fever, chills, palpitations, or
    nervousness. On physical examination, the
    temperature is 37.3 C (99.2 F), and the pulse
    rate is 92/min. Thyroid examination shows warmth,
    tenderness, and moderate enlargement of the left
    lobe of the gland, without fluctuance. Laboratory
    testing shows a leukocyte count of 12,300/µL
    (12.3 109/L), with 82 segmented cells and 3
    bands erythrocyte sedimentation rate is 113
    mm/h. Serum free T4 is 3.0 ng/dL (38.6 pmol/L),
    and TSH is 0.04 µU/mL (0.04 mU/L). CT scan of the
    neck shows no evidence of abscess. Which of the
    following is the most appropriate therapy at this
    time?
  • A- Propylthiouracil 100 mg three times daily
  • B- Radioiodine ablation therapy
  • C- Thyroidectomy
  • D- Systemic antibiotic therapy
  • E- Prednisone 40 mg once daily

14
Case 6
  • A young female has weight loss,
    irritability, diarrhea, very high T4, low TSH,
    and a low RAIU. O/E thyroid gland is painless.
    Serum thyroglobulin level is low. TPO antibodies
    are normal. What is your diagnosis?
  • A- Graves disease.
  • B- Subacute thyroiditis.
  • C- Chronic lymphocytic thyroiditis
  • D- Factitious hyperthyroidism
  • E- Hashimotos thyroiditis.

15
Case 7
  • A 33 year old female gave birth to a healthy
    child 6 weeks ago. She complains of tremors and
    anxiety. T4 is elevated while TSH is low normal.
    In addition to prescribing beta-blockers, which
    of the following would you order to confirm your
    diagnosis?
  • A- Lugol iodine
  • B- Radioactive iodine
  • C- RAU uptake
  • D- Observation

16
Case 8
  • A 32 year old, 4 months post-partum nurse
    comes to you for depression. O/E thyroid is
    enlarged but painless to palpation. Blood tests
    reveal high T3 and low TSH. What is your next
    step in the management of this patient?
  • A- Free T4
  • B- RAI uptake
  • C- A trial of propylthiouracil
  • D- Propranolol
  • E- Observation

17
Case 9
  • 2 months later she comes back with continued
    symptoms of depression. The previously ordered
    RAIU was low. Blood tests now reveal low T3 and
    high TSH. What is your next step in the
    management of this patient?
  • A- No medication, reassurance, and to return
    for rechecking thyroid function test in 3 months
  • B- Give synthroid for short term and
    reassure that she will be fine soon
  • C- refer her to a psychiatrist
  • D- Check for spurious intake of thyroid
    hormone

18
  • Questions?
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